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Inspection on 14/03/07 for Ashleigh Nursing Home

Also see our care home review for Ashleigh Nursing Home for more information

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents needs are assessed before they move to the home, which helps ensure the home will be suitable for them. Staffing numbers are appropriate to the needs of residents and specialist healthcare professionals are called on when necessary for their advice and to help meet individuals` needs. Staff treat residents with dignity and respect. Residents are enabled to make choices in their day-to-day lives for example with meals, activities and dress. Residents enjoy their meals and cultural dietary needs are well catered for. The staff team always welcome visitors to the home, and will help residents and their relatives to keep in contact with each other. Residents` bedrooms are comfortable and homely, with their own personal items. Staff have a good understanding of adult abuse and are aware of what to do should they suspect anything untoward.

What has improved since the last inspection?

The management of complaints has improved since the last inspection. A copy is kept of all complaints and of what action has been taken. The main hallway on the ground floor of the home has been redecorated. Fire safety tests are now being undertaken as required, which is important for promoting the health and safety of staff and residents.

What the care home could do better:

There was evidence that some progress has been made on issues identified at the last inspection but it is only once these things are fully implemented then residents will benefit. For example, the contract has been updated to include the room number, but this contract has not yet been issued to residents. The Statement of Purpose has been updated but this is not yet available to residents. The systems for quality monitoring have been reviewed but again have not yet been implemented. Surveys were sent out to relatives last October but a report on the findings has not yet been completed. A report will assure residents and relatives that there is a point to obtaining their views and will identify any changes that have been made to improve the service. Care planning documentation could be done better, to ensure residents` needs are fully met. Reviews must be undertaken regularly and more detail on care plans is needed. These are issues that were identified at the previous inspection. Medicine management is not at a safe standard. Stocks of medication are not accounted for in the home and medication administration records are not being used properly, which means there is the potential for residents to be given the wrong medication. A number of residents have `as required` medication to control anxiety and behaviour. To ensure residents are not being overmedicated and inappropriately restrained further information on care plans is required stating at what stage it becomes necessary to administer this medication. It should be a last resort. Although there has been some improvement to the recording of what activities has taken place in the home there still needs to be more structured activities in order to give residents some routine and to plan activities that meet individual preferences. There is still some outstanding work to the environment that is urgently required. The ground floor towards the back of the home has black and yellow tape covering the floor, which is unsightly and not very homely for those residents that have bedrooms off that corridor. A bathroom and other areas of the home are in need of redecorating and some furniture is tired and worn. Recruitment practices are still not protecting residents. An immediate requirement was issued because two staff did not have two written references on their files and all staff must have a criminal record bureau check before they start work.Staff training needs to get better to ensure residents are in safe hands at all times and so that staff fully understand residents needs particularly in relation to their dementia. Hoists must be serviced and there must be a risk assessment and measures in place for the prevention of legionella bacteria in the water system. This is to promote and protect residents` health and safety.

CARE HOMES FOR OLDER PEOPLE Ashleigh Nursing Home 17 Ashleigh Road Off Narborough Road Leicester Leicestershire LE3 0FA Lead Inspector Joanna Carrington Key Unannounced Inspection 14th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Nursing Home Address 17 Ashleigh Road Off Narborough Road Leicester Leicestershire LE3 0FA 0116 2854576 0116 2854576 ash_ashleigh@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ashley Cox Mrs Zarina Cox Mrs Zarina Cox Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Learning registration, with number disability (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (21) Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit a named person of category LD(55 ) named in variation application No.1847 dated 12 January 2004. 13th June 2006 Date of last inspection Brief Description of the Service: Ashleigh Nursing and Residential Home is registered to admit up to 21 people over 65 years of age who have dementia or mental health care needs. The home is situated near to the centre of Leicester and is a short walk away from main bus routes. Accommodation is available to both the ground floor and first floor, this being accessed by a passenger lift. Residents have their own private bedrooms or share in double bedrooms. All areas of the premises are accessible for people with mobility impairments. The rear of the building offers a small garden area with a patio. The laundry facilities are situated in a separate building. All external doors are alarmed. The current range of fees charged fall between £291 and £475 per week. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight hours on 14th March 2007. This was the home’s second key inspection in the inspection year. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the quality of their care by checking records, discussion with them and with staff and observation of care practices. Three residents were spoken with but due to their dementia two of these residents did not make comment about the home. A relative and two staff members were spoken with and the manager and the owners of the home were also available for discussion and feedback throughout the inspection. Staff records were looked at to make sure staff get the training they need and checks are carried out on staff before they commence their employment. A partial tour of the premises also took place in order to assess environmental standards. The registration certificate for this home is currently being challenged because one of the registered providers is down as being the registered manager. Evidence that the manager has already been registered is in the process of being supplied to the Commission. What the service does well: What has improved since the last inspection? The management of complaints has improved since the last inspection. A copy is kept of all complaints and of what action has been taken. The main hallway on the ground floor of the home has been redecorated. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 6 Fire safety tests are now being undertaken as required, which is important for promoting the health and safety of staff and residents. What they could do better: There was evidence that some progress has been made on issues identified at the last inspection but it is only once these things are fully implemented then residents will benefit. For example, the contract has been updated to include the room number, but this contract has not yet been issued to residents. The Statement of Purpose has been updated but this is not yet available to residents. The systems for quality monitoring have been reviewed but again have not yet been implemented. Surveys were sent out to relatives last October but a report on the findings has not yet been completed. A report will assure residents and relatives that there is a point to obtaining their views and will identify any changes that have been made to improve the service. Care planning documentation could be done better, to ensure residents’ needs are fully met. Reviews must be undertaken regularly and more detail on care plans is needed. These are issues that were identified at the previous inspection. Medicine management is not at a safe standard. Stocks of medication are not accounted for in the home and medication administration records are not being used properly, which means there is the potential for residents to be given the wrong medication. A number of residents have ‘as required’ medication to control anxiety and behaviour. To ensure residents are not being overmedicated and inappropriately restrained further information on care plans is required stating at what stage it becomes necessary to administer this medication. It should be a last resort. Although there has been some improvement to the recording of what activities has taken place in the home there still needs to be more structured activities in order to give residents some routine and to plan activities that meet individual preferences. There is still some outstanding work to the environment that is urgently required. The ground floor towards the back of the home has black and yellow tape covering the floor, which is unsightly and not very homely for those residents that have bedrooms off that corridor. A bathroom and other areas of the home are in need of redecorating and some furniture is tired and worn. Recruitment practices are still not protecting residents. An immediate requirement was issued because two staff did not have two written references on their files and all staff must have a criminal record bureau check before they start work. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 7 Staff training needs to get better to ensure residents are in safe hands at all times and so that staff fully understand residents needs particularly in relation to their dementia. Hoists must be serviced and there must be a risk assessment and measures in place for the prevention of legionella bacteria in the water system. This is to promote and protect residents’ health and safety. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate The admissions procedure ensures that the home is suitable in meeting prospective residents needs. However, up to date information about the home is not available so that prospective residents can make an informed decision to move there and their rights and responsibilities are not protected unless they are issued a contract with the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the files of all three residents’ case tracked there were copies of the placing authority’s community care assessments and nursing assessments. The assessment information obtained is detailed and gives the staff at the home some insight into the level of support these residents need. At the last key inspection a requirement was made to update the Statement of Purpose so that residents and their relatives have up to date information about the home. The registered provider showed the updated document but this is not yet freely available. A relative that was spoken with did not see any written information about the home. The relative said this would have been Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 10 helpful because due to illness she was unable to come and visit the home before her relative-in-care moved in. There was no evidence on the files seen that the three residents case tracked have been issued a contract / terms and conditions with the home. The registered provider showed a copy of the amended contract. This has been amended to include the room number, as recommended at the last key inspection. This must now be put into use. It is a requirement that all residents (or their relative / representative) are issued one. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Care planning arrangements fail to ensure residents’ health and personal care needs are appropriately met and their rights are respected and upheld. Medicine management does not protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three residents have care plans in place that cover aspects of their social, health and personal care needs but none of these plans have been reviewed since November last year. This does not ensure that any changes in need and how support is given have been identified. This is an outstanding requirement from the previous inspection. One resident case tracked has “fluctuating nutritional intake” and another resident case tracked has “risk of weight loss” identified in their care plans but no nutritional screening is carried out for either of these residents. There were care plans and risk assessments seen for agitation and aggressive behaviour, but there needs to be more detail on these plans, to ensure this behaviour is responded to appropriately and that residents’ rights are upheld. It was evident from daily records and from discussion with the manager that Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 12 residents are administered ‘as required’ medication to relieve anxiety and agitation. To ensure residents are not inappropriately restrained by medication then the relevant care plan must provide clear guidance to staff on strategies to defuse a situation and at what stage if this does not work does medication need to be given. There has been some improvement with risk assessments since the last inspection. Two residents’ that were case tracked have bed rails and risk assessments for their use were seen on their files. It is recommended, however that more specific detail on the risks associated with their use is added for example, in case the resident can climb over them, get caught in them or suffocate from the buffer that is used to cover the rail. There was evidence on the files seen that pressure sore assessments are now being regularly reviewed. There was evidence on care plans and daily records that health care professionals are involved in residents’ care when appropriate. For example, a physiotherapist assessed a resident for the use of a frame, in order for him to mobilise around the home more safely. Staff were observed interacting with residents in a respectful and dignifying manner. A relative states in a survey “the staff are always friendly and very caring…no one is left out” At the start of the inspection one of the registered providers was observed giving medication. The registered provider was not signing the Medication Administration Record after administering medication to each resident. The registered provider explained that she was going to sign the records after. This is dangerous practice because it does not ensure that all residents will be given their medication as prescribed. Errors were found with all three drugs audited. Stocks of medication are not being monitored, as the remaining amounts of drugs do not tally with what has been signed as given. For one drug, which is an ‘as required’ medicine for agitation twelve tablets had been signed as given, which mean sixteen tablets should remain but there was only one. This is a large discrepancy and is of concern. It is recommended that the manager carry out regular audits following a drug round, in order to identify where errors are being made and any registered nurses that are not competent in this task. One of the medicines audited the instruction is half a tablet to be administered for each dose. The manager reported that the other half of each tablet, when removed from the blister is disposed of. This must be recorded on the medication administration record (MAR) so that all remaining stocks are accounted for. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Residents experience a homely and relaxing lifestyle, but further improvements to the provision activities will have a positive affect on residents’ quality of life and will satisfy their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection staff members were observed sitting with residents and interacting with them in a meaningful manner. A relative spoken with said that staff play ball and will draw pictures with residents. A record of activities is now being kept but still without a planned programme of activities, this does not ensure a variety of activities are offered, and that any interests identified in individuals’ assessments are catered for. The manager reported that a new outside entertainer is visiting the home once a month for sing-alongs and other activities. There was evidence seen that this has been booked. A relative spoken with confirmed that she is always made to feel welcome when she visits and that she either visits her mum in the main lounge or they can choose to go to her bedroom to have some privacy. Staff spoken with gave examples of how they ensure residents are still able to exercise choice and control in their lives, for example, with what to wear, meals and what Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 14 activities they like to participate in. One resident that currently has one to one support was observed being assisted to walk around the home safely, as she wished. One resident is confined to his bed due to his physical condition. This increases the risk of social isolation therefore more attention should be made of this in the resident’s care plan. On the day of the inspection the main meal was either roast beef, with carrots, parsnips and potatoes or chicken curry and rice. The meals served looked appetising and residents were observed enjoying their meal. Menu records show that meals are varied and nutritious. The cook was spoken with and demonstrated a good awareness of the different cultural dietary needs of residents. Menu records and other information available to the cook show that these diverse needs are well catered for. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Improvements to the management of complaints means that residents are assured their concerns and complaints are taken seriously and acted on. Staff are aware of their responsibilities in accordance with Safeguarding Adults procedures, which helps ensure residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A relative spoken with confirmed she knows how to make a complaint and feels confident that any concerns are listened to. The relative mentioned a recent complaint that she made to the manager about her relative-in-care’s state of dress; the relative confirmed she is content with how it was dealt with. At the last inspection there was no available complaints records. This time, there were records seen including the complaint that the relative mentioned and the appropriate action that was taken. On the afternoon of the inspection the manager was giving in-house training into adult abuse and the local Leicestershire Safeguarding Adults procedures. The training was in the form of a workbook that Leicestershire County Council have issued to the home. Both staff spoken with reported finding the training helpful, and demonstrated an understanding of different forms of abuse and of their responsibility to alert the manager of any allegation or disclosure of abuse. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is poor. Very limited progress has been made to improving the environment. Further work is required, so that the home is comfortable and safe for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered provider reported spending money on a new motor for the lift and a new heating system. Since the last key inspection the main hallway on the ground floor has been redecorated and flooring in the ground floor bathroom has been replaced. The bedrooms of the case tracked residents were homely and personalised with their own items such as pictures and ornaments. In one of the shared bedrooms seen a fire door that divides two bedrooms has a hole in it where the handle used to be; this does not look nice but more importantly it does not respect residents’ privacy. Paintwork is dated and coming off the walls in some parts of the home and furniture in communal areas is torn and stained. A relative has pointed out in their survey that “a lick of paint would make [the home] look nicer”. Flooring Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 17 towards the back of the home is still taped up with black and yellow tape, and has been like this at the previous two inspections. A bathroom on the first floor is in desperate need of work. There appeared to be damp or some sort of fungus on the interior wall above the bath. The environment appeared clean and hygienic throughout the home. Some bathrooms did not contain any hand soap, which is important for preventing spread of infection. The laundry facilities are sited in a separate building at the back of the home, and are appropriate to the needs of residents. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor Recruitment practices are still placing residents at risk of harm and lack of staff training does not ensure residents’ needs are appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All four completed residents surveys state that staff are always available when their assistance is needed. A relative spoken with also confirmed that there are always staff about to speak to. The care rota confirmed that hours are always covered and that staffing numbers are based around the needs of residents. One resident currently has additional one to one staffing paid for by the primary care trust. Four staff files were randomly selected; two of these files were for staff members that have commenced employment since the last inspection. It was not stated on any of the files when each staff member commenced their employment. This had to be figured out by looking at staff rotas. The two most recently employed staff members each only had one written reference, when there should be two. An immediate requirement was issued in respect of this and responded to within the set timescale with appropriate action taken. The references seen on file are not dated so it is not possible to ascertain whether these were returned before the staff member commenced employment and the name of the referee is not included on one of the references. One of the four staff members does not have a current criminal Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 19 record bureau check (CRB). The CRB on file is from a previous employer. The umbrella body that is used for CRB checks confirmed that another CRB has been applied for. Only three of the seventeen care staff currently has a National Vocational Qualification in Social Care. There was evidence in the form of letters from a training provider that all care staff are being enrolled onto NVQ level 2. There was also evidence seen indicating that Leicester City Council are working with the home on identifying training needs of staff and relevant courses. The staff files and training matrix show that staff are not up to date with their mandatory health and safety training, particularly food hygiene and infection control. There was no evidence on the files of the newest staff that they have had an induction and although a senior care worker confirmed they are a moving and handling trainer and have provided a half-day moving and handling course to the new staff there is no evidence of this on their files. This is a home that provides care to older people with dementia but dementia training has not been provided to all staff. Care plans for communication refer to using a technique called ‘reality orientation’ when interacting with residents with dementia. A staff member that was spoken with confirmed they have not had any training in dementia and did not know what ‘reality orientation’ means. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, and 38 Quality in this outcome area is adequate Further improvements to the management approach are required for the protection of residents’ health and safety and to ensure the home is effectively run and in the best interests of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a deputy manager was appointed at the home, which was so that all management tasks could be carried out, and that health and safety and care home regulations are complied with. The manager and registered provider reported that unfortunately the deputy manager left her post with little notice and therefore not all improvements made have been maintained since her departure. This is evident particularly in residents’ documentation. (Refer to Outcome area on Health and Personal Care) The manager only has a limited number of hours per week dedicated to managerial and administrative tasks. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 21 Accident records were looked at and cross-referenced with the notifications the Commission have received. Evidence suggests that all notifications as required by law are now being made to the Commission. This is so that the home can be effectively regulated. The fire safety log shows that fire alarm testing and drills are now being carried out as required and records seen show that fridge and freezer temperatures are being monitored on a daily basis. The servicing of hoists is now overdue according to records and there is no risk assessment in place identifying necessary measures for the prevention of legionella bacteria in the water systems. As mentioned in the previous outcome area not all staff members have had the required health and safety training such as food hygiene, moving and handling and first aid. There are currently no monies belonging to residents held in the home. Social Services act as appointee for two residents but currently their money is in their bank account. Copies of bank account records should be held at the home as these belong to the residents and also so that these records can be inspected. A resident spoken with confirmed that they have access to money when they want it. A report on the results of the surveys on the quality of service, that were sent out to relatives in October 2006 has still not been completed. This means that residents and relatives have not seen any benefit to these questionnaires and in giving their views. The registered provider talked of a set of standards that are included in the Statement of Purpose that will be used to monitor the quality of the service provided. There now needs to be evidence at the next inspection that this system is implemented. Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 X 2 X 2 X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement Ensure all residents are issued with a signed statement of terms and conditions / contract when they move to the home. The registered provider must ensure residents care plans are accurately maintained including regular evaluation and reviews. This is an outstanding requirement from the previous inspection, initial timescale 16/07/06 not met. Ensure nutritional screening is carried out and kept under review for residents that have identified nutritional and dietary needs. This is to safeguard residents’ health and wellbeing. Ensure suitable arrangements are in place for the recording, handling, safekeeping and safe administration of medicines. This refers to: 1. Signing the medication administration record immediately after administering medication to a resident. 2. Monitoring staff DS0000001885.V330029.R01.S.doc Timescale for action 01/07/07 2. OP7 15 01/06/07 3. OP8 13 01/07/07 4. OP9 13 01/05/07 Ashleigh Nursing Home Version 5.2 Page 24 5. OP9 12 6. OP19 12 7. OP24 23 8. OP29 19 9. OP30 18 10. OP38 13 competency in administering medicines. 3. Keeping an accurate record of quantities of medication held in the home. Ensure all residents that have ‘as required’ medication for controlling anxiety and behaviour that there are clear and detailed care plans on when it becomes necessary for this medicine to be administered. The registered provider must ensure that all floor coverings in the home are fit for purpose. This is an outstanding requirement from the previous inspection, initial timescale 16/08/06 not met. Ensure all residents’ bedrooms provide residents with full privacy. The fire door with a hole in it dividing two bedrooms must be fixed or replaced. Ensure that a criminal records bureau check and two written references are obtained before a new staff member commences employment. This is an outstanding requirement from previous inspection, initial timescale 16/07/06 not met. Ensure that all staff members receive all required training appropriate to their role. This includes all mandatory health and safety training, induction, dementia training and any other training relevant to the needs of residents. This is to ensure that residents are in safe hands at all times. In consultation with the relevant authority, ensure hoists and other such equipment are serviced regularly and that there DS0000001885.V330029.R01.S.doc 01/06/07 01/08/07 21/04/07 16/04/07 01/08/07 01/08/07 Ashleigh Nursing Home Version 5.2 Page 25 are relevant measures in place for the prevention of Legionella, in accordance with health and safety legislation. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP1 OP12 OP12 OP21 OP26 OP28 OP31 Good Practice Recommendations Ensure that the Statement of Purpose / Service User Guide is available to prospective residents / relatives and that all residents / relatives have a copy on admission. In consultation with residents / their relatives provide a structured programme of recreational activities. For residents that are cared for in bed consider the risk of social isolation and mental deterioration and what measures can be put in place to help minimise this risk. Ensure residents have sufficiently maintained bathrooms. and hand washing facilities. Ensure liquid soap is available in all bathrooms, to ensure cleanliness and to prevent spread of infection. Continue enrolling all staff on National Vocational Qualifications courses. Review current management arrangements at the home, paying attention to number of hours allocated to managerial and administrative duties. Ensure the system for monitoring and reviewing quality of care, including seeking the views of residents and stakeholders, is fully implemented. OP33 Ashleigh Nursing Home DS0000001885.V330029.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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